CDS - Medical Records

Overview

St. Mary's General Hospital, located in Passaic, NJ, is a community-based tertiary medical center focused on providing quality, compassionate care. It is an acute care hospital providing a broad range of services including cardiovascular services as well as a comprehensive program for cancer care. The hospital is also a center of excellence for maternal-child health and outpatient behavioral health services.  It is the only hospital in Passaic and with over 550 physicians and 1,000 employees, and is one of the largest employers in the county. Every member of the St. Mary's General team is committed to providing respectful, personalized, high-quality care. St. Mary's General Hospital is a member of Prime Healthcare, which has been lauded as a "Top 15 Healthcare System" by Truven Health Analytics. For information, visit www.smh-nj.com.

 

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. The CDS will perform other duties as assigned or required.

Qualifications

EDUCATION, EXPERIENCE, TRAINING 1. Medical Graduate, PA or Nursing Graduate required2. Minimum of three one (1+) years clinical experience in an acute care setting3. Knowledge of care delivery documentation systems and related medical record documents4. Knowledge of age-specific needs and the elements of disease processes and related procedures5. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.6. Excellent written, and verbal communication skills and critical thinking skills.7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.8. Working knowledge of inpatient admission criteria.9. Ability to work independently in a time-oriented environment.10. Computer literacy and familiarity with the operation of basic office equipment.11. Assertive personality traits to facilitate ongoing physician communication.12. ECFMG Certificate or RN license preferred.13. Prior Case Management Experience preferred.14. Working knowledge of the Medicare reimbursement system and coding structures   preferred.15. Current BCLS (AHA) certificate upon hire and maintain current preferred.16. ACLS Certificate preferred.

 

 

Pay Transparency

St. Mary's General Hospital offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $28.00 to $43.40. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf